Good Faith Estimate Requirements: What Therapy Practices Must Do

Clients with no coverage for the service, and clients who have coverage but don't want a claim sent to their plan.

The federal rule calls both groups "uninsured (or self-pay)" individuals (45 CFR 149.610(a)). This post covers estimates for those clients only.

Uninsured and self-pay clients

When a client schedules, your team has to ask whether they have coverage and, if they do, whether they want a claim sent for this service. Then tell every uninsured or self-pay client that an estimate is available.

Clients enrolled in a federal health care program aren't treated as self-pay just because they don't want to use that coverage (CMS good faith estimate decision tree).

When a cost question counts as a request

Any discussion or question about the cost of a service counts as a request for an estimate (45 CFR 149.610(b)(1)(iv)). A client who asks what therapy will cost on an intake call has started the clock.

Next step: add the two coverage questions and a line about estimates to your intake script.

1 business day or 3 business days, depending on how far ahead the session is booked and whether the client asked.

• Scheduled 3 or more business days in advance: send it within 1 business day of scheduling.
• Scheduled 10 or more business days in advance: send it within 3 business days of scheduling.
• Requested by the client: send it within 3 business days of the request.
• Scope changes after scheduling: send a new estimate at least 1 business day before the session.

These timeframes come from 45 CFR 149.610(b)(1)(vi) and (vii). CMS's patient page describes business days as Monday through Friday (CMS patient rights page).

Next step: have your scheduling system flag self-pay bookings so the estimate goes out the same day.

Yes. One estimate can cover recurring sessions for up to 12 months.

The estimate has to spell out the expected scope, such as the timeframe, how often sessions happen and the total number (45 CFR 149.610(b)(1)(x)). CMS uses "periodic counseling services" as an example of recurring care (CMS good faith estimate FAQs, Part 2).

If care runs past 12 months, send a new estimate and explain what changed. If the plan changes sooner, for example weekly sessions become twice weekly, that's a change in scope and needs a new estimate at least 1 business day before the next session.

For therapy practices a 12-month estimate tied to the treatment plan is a simple way to stay current.

Next step: set a reminder to reissue each recurring estimate before it hits 12 months or the frequency changes.

Client details, a plain description of the service, itemized expected charges with codes, provider identifiers and the required disclaimers.

• Client name and date of birth
• A plain-language description of the primary service and its scheduled date, if there is one
• An itemized list of expected services grouped by provider, with diagnosis codes, service codes and expected charges
• Each provider's name, NPI and TIN, plus the state and office location where services will happen
• Any related services that need separate scheduling, listed under their own disclaimer

The full list is in 45 CFR 149.610(c).

Required disclaimers

• There may be other recommended services that have to be scheduled or requested separately.
• The estimate is only an estimate, and actual services or charges may differ.
• The client can start patient-provider dispute resolution if the bill is substantially higher than the estimate, with instructions on how, and starting it won't affect the quality of care.
• The estimate is not a contract and doesn't require the client to get services from the providers listed.

Written delivery and record keeping

The estimate has to be written, on paper or electronically, in a form the client can save and print. You can walk a client through it by phone, but the written copy still has to go out (45 CFR 149.610(e)).

It becomes part of the medical record. A client can ask for a copy of any estimate you gave them in the last 6 years (recordkeeping rule, 149.610(f)).

CMS publishes a model good faith estimate form, and its own text says using it is not required.

Next step: check your template against this list line by line.

If a provider's bill is at least $400 over that provider's estimate, the client can ask a federal dispute resolution entity to decide what they owe.

What triggers a dispute

"Substantially in excess" means total billed charges at least $400 more than the total expected charges on that provider's estimate (45 CFR 149.620(a)). The client has 120 calendar days from receiving the first bill with those charges to start the process.

What the practice must send

Once the entity tells you the dispute is eligible, you have 10 business days to send a copy of the estimate, a copy of the bill and, if you have it, documentation that the higher charge was medically necessary and caused by circumstances you couldn't have foreseen (45 CFR 149.620(f)(2)). CMS says providers get an emailed link to the federal portal to upload these (CMS provider guidance).

The entity then has 30 business days after it receives that information to decide.

What you cannot do while it is pending

• Move the bill to collections or threaten to
• Add late fees on the unpaid amount
• Take or threaten any retaliation against the client for using the process

If the bill is already in collections, the rule says you should cease collection efforts.

These limits are in 45 CFR 149.620(c)(5) and (6), and CMS repeats them in its guidance for providers.

Settling before a decision

You and the client can still agree on an amount. If you settle, notify the entity no later than 3 business days after the agreement, and reduce the client's amount by at least half of the administrative fee they paid (settlement rule, 149.620(f)(1)).

Next step: name one person who receives dispute notices and uploads documents, so a 10-business-day deadline doesn't slip.

In a dispute, the gap between what you billed and what you estimated, plus the wait while the dispute runs.

Revenue held up in a dispute

If a listed service is billed above its estimate and you can't give credible information that the difference was medically necessary and based on unforeseen circumstances, the entity sets the amount at the estimate. For a service that wasn't on the estimate at all, the same finding sets it at $0 (45 CFR 149.620(f)(3)).

If the entity's amount comes in below your billed charges, the client's amount is also reduced by the administrative fee they paid (fee rule, 149.620(g)). Win or lose, the bill stays out of collections and can't accrue late fees until the dispute closes.

Good-faith errors and corrections

An honest error made with reasonable due diligence doesn't break the rule by itself if you correct it as soon as practicable. If the session happens before the fix, the bill can still go to dispute (45 CFR 149.610(f)(3)).

Next step: stop patient balance follow-up on a disputed bill the day the notice arrives. A review of self-pay balances and write-offs shows how much of that revenue depends on estimates being right.

The convening provider, which is the provider that gets the request and schedules the main service.

The rule puts the duty on that provider (45 CFR 149.610(a)(2)(ii)). In group practices that can mean one scheduling team runs the process for every clinician. The rule also has the convening provider ask any co-provider for its estimate details within 1 business day, but CMS says estimates don't have to include co-provider costs until HHS finishes future rulemaking (CMS good faith estimate decision tree).

Notices on your website and in the office

Post a clear notice that estimates are available on your website, where search engines can find it, in the office and where scheduling happens. Say it out loud when clients schedule or ask about cost, and offer it in accessible formats and the languages your clients speak (45 CFR 149.610(b)(1)(iii)).

Front desk and intake steps

1. Ask about coverage when the session is booked. This fits naturally with verifying coverage before the first session.
2. Ask insured clients whether they want to use their plan for this service.
3. Tell uninsured and self-pay clients an estimate is available.
4. Send the estimate within the deadline.
5. Reissue it when the scope changes or 12 months pass.
6. File it in the medical record.

The staffing cost is front desk and billing time on every self-pay booking. Next step: write these six steps into your intake checklist instead of relying on memory.

Thirteen rules cover most of the day-to-day work.

Section numbers refer to 45 CFR. Read the full text at 45 CFR 149.610 and 45 CFR 149.620.

Next step: keep this table at the desk where self-pay clients get scheduled.